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Quality Measures Need to be Field-Tested, Researchers Find

Jul 26, 2005

ALEXANDRIA, Va. -- A group of researchers has developed a set of "quality indicators" to measure the quality of antibiotic use in hospitalized patients with lower respiratory tract infections (LRTIs) by combining scientific evidence with expert opinion, according to an article in the August 15 issue of Clinical Infectious Diseases. However, the researchers found that simply developing the quality indicators was not enough: field-testing was also necessary, as some indicators approved by an expert panel proved unworkable in daily practice.

Antibiotics are prescribed to more than two-thirds of patients with LRTIs in Europe and the United States. Over-prescribing and inappropriate use of antibiotics can result in bacterial drug resistance, a burgeoning problem in medicine. The creation and application of effective indicators that would tell physicians when and how to prescribe antibiotics could contribute to more effective treatment of LRTIs and lessen the risk of promoting drug resistance. Insurance companies and federal government programs are moving toward linking physician payments to quality indicators.

Researchers in the Netherlands developed a set of quality indicators for antibiotic use in LRTI by combining recommendations from published guidelines and the available literature and investigating the scientific evidence to determine how well each performed. A panel of experts then judged the indicators' relevance to patient health, reduction of drug resistance, and cost-effectiveness. The best indicators combine "the available evidence and expert opinion to assess aspects of care for which evidence alone is insufficient, absent, or methodologically weak," according to Jeroen A. Schouten, MD, of Radboud University Nijmegen Medical Centre, lead author of the article.

Establishing the indicators' practical applicability to patient care was the final step. The indicators were tested for measurability, reliability, opportunity for improvement, and whether they were usable in a variety of healthcare settings. Four measures approved by the expert panel were rejected after practice testing determined they were impractical or not useful in particular settings. For example, all members of the panel agreed that the time between performance of blood cultures and first antibiotic administration should be measured. "But in reality," the authors write, "this could be done in only 25 percent of patients."

A final list of 15 quality indicators was deemed to be practicably applicable in the researchers' demonstration hospital set, although the list could vary at different healthcare settings. This set included such recommendations as "timely initiation of antibiotic therapy," "choosing initial antibiotic therapy according to current national guidelines," and switching from a broadly acting antibiotic to a more focused one once the pathogen is known.

"It is feasible that physicians already use some of these indicators in daily practice, mainly those related to patient outcome in large studies and those required for accreditation review," Schouten said.

Effective treatment of LRTI patients, while minimizing the risk of drug resistance, hinges on physicians' use of the indicators. "Why does a professional not act according to a certain indicator?" asked Schouten. "We believe that a strategy that is tailored to the perceived barriers of judicious antibiotic use will have the largest chance of succeeding." The investigators are performing further research to test the effect of such a strategy.